The Great Fellatio Debate: How Safe Is Oral Sex?

What
are the chances of getting HIV through fellatio? This is
probably the sexual question gay men ask most frequently, and it's one many
straight women are asking as well. But people cannot get a consistent
answer. ''One day you hear it's not a risk,'' says AIDS activist Spencer
Cox, ''and the next day you hear, Don't even think about putting your
tongue on a cock.''

Cox is exaggerating only slightly. At the
International Conference on AIDS this summer, Gay Men's Health Crisis
sponsored a standing-room-only forum on the subject. Three scientists
explained that although some people have been infected through oral sex
such cases appear to be rare. Despite the widely reported discovery that
monkeys can easily be infected by swabbing the back of their tongues with
SIV, the simian cousin of HIV, humans usually catch the AIDS virus sexually through anal or vaginal intercourse.

The panel's last speaker was gay activist and
author Eric Rofes. ''The oral sex panic,'' he declared, arises from ''a
deeply rooted anxiety about what we do with our bodies with other males''
and from society's dismissal of ''the authentic need that many men have to
exchange semen.'' Rofes ended by exhorting the audience to ''hold our
ground'' on oral sex. ''If you want to make it even more safe, don't let
him come in your mouth. But keep doing it!''

The very next day,
researcher Timothy Schacker presented data on people newly infected with
HIV. In 12 cases, Schacker had been able to identify the specific sexual
episode that most likely transmitted the virus; in four cases, the riskiest
activity was fellatio. In two, the men's partners confirmed their stories.
Schacker concluded that ''oral transmission of HIV may occur more often
than previously recognized.''

To Schacker, a key finding was
that the men in his study were having oral sex without a condom about 20 times mo
re frequently than they were having unprotected receptive anal sex. So,
although the risk for a single act of fellatio is much less than for anal
sex, Schacker says, ''if you perform oral sex enough times, your cumulative
risk could be substantial.''

Schacker's study is too small to be
conclusive. But it documents something many clinicians and researchers have
noticed: a persistent trickle of infections among people who say fellatio
is their primary risk factor. Four out of 102 newly infected gay men in
Amsterdam cited oral sex as their riskiest behavior, one out of 50 in
Boston, three out of 49 in San Francisco, one out of 41 in a second S.F.
study, and six out of 28 in Stockholm. In addition, at least a dozen more
cases are in the scientific literature, and researchers in Sweden and New
York are preparing to publish new reports of individuals getting infected
through fellatio.

On the other hand, there is persuasive evidence that
HIV is hard to catch through oral sex. Several studies of heterosexual couples, in which one partner was HIV-positive, found that none of the women wh
o performed fellatio but used condoms for vaginal intercourse got infected.
In a large American study, none of the 147 men who had oral but not anal
sex got infected.

Case reports are also inconclusive. One man who
contracted HIV through oral sex had performed fellatio on hundreds of
partners a year, often to ejaculation, in San Francisco, the epicenter of
the epidemic. Yet this man repeatedly tested HIV-negative until 1989, a
bullet-dodging feat that would be virtually inconceivable had he been
having that much anal sex. This suggests oral sex is ''low risk,'' says
Paul O'Malley, an official with the San Francisco Department of Health who
helped document this case. But he points to another man infected through
oral sex, who had fellatio with his HIV-positive boyfriend for only a few
months.

These numbers may seem small, but ''do you know how hard it is to
become a case report?'' asks O'Malley. Not even the Centers for Disease Control, which collects AIDS statistics, asks what sex act transmitted the
virus.

The Voice faxed a survey to AIDS doctors across the country. Of
the 40 who responded, 17 had patients who said they were infected through
performing fellatio. The doctors ''strongly believe'' 61 of these patients.
This represents only a sliver of the thousands of people with AIDS they
have treated, but the total number is too substantial to dismiss.

Such
stories are not uncommon in the gay community. Even Rofes, the activist who
urged gay men to keep having oral sex, knows people-''including a
friend''-who say they were infected via fellatio. Nevertheless, he believes
the risk is ''near negligible.''

To resolve the contradictions
that inevitably arise from small studies and anecdotal reports, people look
to large epidemiological studies. In the U.S., most of these have been
conducted among gay men. What's more, most major investigations of
heterosexual transmission have taken place in Africa and Asia, where cultural mores can make it hard to track infections through fellatio. Ann Duerr,
an AIDS researcher with the CDC, recalls that when she worked in Rwanda,
''I couldn't even get my nurses to ask about oral sex. It was, 'Put what in
your mouth?' '' As a result, AIDS educators have skimpy data to pass on to
their female clients.

Still, all major studies have found that fellatio
is much safer than anal or vaginal sex. Unfortunately, they prove nothing
else. ''To say oral sex is low risk, and that people can engage in that
activity over long periods of time without worrying about it, would be the
wrong inference,'' says Victor DeGruttola, an AIDS statistician. Because of
the difficulty of determining which sex acts transmitted the virus, the
risk of oral sex ''cannot be determined from a general epidemiological
study,'' DeGruttola says.

Nowhere does this uncertainty show up more
starkly than in risk estimates. At one extreme, oral sex was reckoned to be
only 5.3 times safer than anal sex. But another estimate concludes that it is 100 times safer. The researchers who came up with these two
figures-James Koopman and David Ostrow, respectively-told the Voice that
they amounted to little more than back-of-the-envelope
calculations.

Another calculation comes from a study involving almost
3000 men. Those who reported having no anal sex in the six months before
their HIV test were about 32 times less likely to test positive than those
who did. Lead researcher Roger Detels says this figure can serve as a rough
gauge of fellatio's risk. Very rough indeed, because the margin of error is
extremely wide: Men who avoided anal sex could have been anywhere from nine
to 263 times safer.

Part of the difficulty is that infectiousness varies.
People with AIDS can transmit the virus more easily in late-stage illness,
and probably also in the first few months after they are infected. But
during the intervening years, any STD or genital tract inflammation can
dramatically increase the amount of HIV in semen. Similarly, uninfected people
are probably more vulnerable to catching HIV when they are sick, and maybe
even when they are just feeling run-down.

Risk estimates are for
populations. But a person about to suck a particular penis needs to know
the chances of infection then and there. ''That has not been measured,''
says Richard Elovich, an AIDS educator at GMHC, ''and really can't be.''

How people have oral sex varies tremendously, and that can make
all the difference. ''I drew the line at taking cum in my mouth,''
says Joey, who asked that his real name not be used. Joey's policy is
common, and many gay men believe that by keeping semen out of their mouths
they will keep HIV out of their bodies. Scientists agree that this reduces
the chance of infection-if only because precum is a smaller amount of fluid
than ejaculate-and in most documented cases where researchers asked,
infected men had taken semen into their mouths. (On such occasions, many
experts suggest spitting it out because swallowing can bring the virus intocontact with cells along the esophageal tract. Rinsing with mouthwash,
peroxide, or hard liquor ''would probably help,'' says a CDC spokesperson.)
But other factors are also important.

At an all-weekend party, Joey took
several drugs: Ecstasy, K, and cocaine. While high, he had sex with a guy
he knows to be HIV-positive. During their two-hour liaison, they blew each
other repeatedly and vigorously. ''Between men,'' says Joey, ''cocksucking
is almost a competitive thing: Can you take the whole dick down your
throat?'' In doing that, Joey created ''a shitload of friction'' against
the back of his throat.

Researchers believe deep-throating raises the
risk of infection, even without ejaculation. In most people, the lining of
the mouth probably has to tear for HIV infection to occur, according to
London University researcher Thomas Lehner, and that is more likely to
happen with rough oral sex.

In a study published last year, Lehner
biopsied tissues from the mouth, vagina, rectum, and foreskin. He looked for the cells HIV is believed to infect during sexual transmission, called
CD4+ Langerhans. He discovered that these vulnerable cells rarely lie near
the surface of tissues that line the mouth, though they abound deeper down.
By contrast, most of the foreskin and vaginal specimens showed a lot of
Langerhans cells near the surface. ''There is a possibility'' that
infection could occur in the mouth without tissues tearing, says Lehner,
''but the chances are much lower'' than with vaginal or rectal
sex.

Deep-throating may carry extra risk, because the throat may be more
susceptible to infection than the mouth. The tonsils are ''anatomically
adapted'' to trapping incoming pathogens, says Sarah Frankel, an expert in
this subject. Ejaculating or rubbing precum into the tonsils raises the
danger. What's more, the nearby adenoid gland has a lining which contains
Langerhans cells on its surface. And special ''dendritic'' cells deep in
the tonsils and adenoids can hook HIV from the surface with long tendrils. Coming on the front of the teeth is a whole different thing from ejaculating in
the back of the throat,'' says Frankel. If friction during fellatio exposed
any vulnerable cells, ejaculation may not be necessary for infection.
Precum contains ''quite a bit of virus,'' says Harvard's Deborah Anderson,
an expert on HIV in genital fluids. Saliva can inhibit HIV, but recent
research shows this varies greatly from person to person.

About three
weeks after his episode of hot and heavy oral sex, Joey came down with
flu-like symptoms, and blood tests verified that he was undergoing
''conversion illness,'' the sign that a person is becoming
HIV-positive.

The way Joey had oral sex is common among gay men, but not
among women, says sex researcher Pepper Schwartz, who coauthored a study of
6000 gay, lesbian, and heterosexual couples. ''Very few straight women will
go beyond the gag reflex, but that is almost normative among gay men.''
Schwartz also found that gay men are ''far more likely to swallow semen. Women basically
don't like to swallow and don't do it most of the time.'' From her
interviews, Schwartz concluded that only about 20 per cent of women
consistently swallowed, whereas about 80 per cent of the gay men
did.

Schwartz, who published her couples book in 1983, thinks many gay
men may have modified their technique because of AIDS. A recent New York
study confirms her hunch: Only 15 per cent of gay men took semen in the
mouth. But the urge ''is still there,'' as Schwartz attests. In the Voice
survey, doctors with a mostly gay clientele were much more likely to have
patients who were infected through fellatio.

Gay men are also at higher
risk because they have, on average, more partners than straight women. Joey
had two other sexual episodes in the month before his conversion illness.
Both times, he was the one being sucked. (There are at least four case
reports of men being infected by having their penises sucked. But that is
not considered a high-risk activity because saliva contains much less HIV than semen.) From one of the men who sucked him off, Joey
got gonorrhea, and it's possible that HIV piggybacked on that
infection.

Finally, Joey might have had an oral infection during that
fateful weekend. A study of more than 1100 HIV-negative gay men found that
more than a quarter had gingivitis, or inflammation of the gums, which can
facilitate infection. Dentists say that many people don't notice
gingivitis. And all researchers suggest using condoms if people have just
flossed or have any cuts or sores in the mouth.

Joey admits that ''no one
ever said oral sex was perfectly safe.'' But like a lot of people, he
thought the risk was so remote that he ''had a better chance of winning the
lottery than picking up HIV from sucking dick.'' So when he first found out
he was infected, he felt stunned.

Why don't people use condoms?
A few do. But of the 80 to 90 per cent of gay men who engage in fellatio, a
mere 3 to 6 per cent rubber up their partners.

Less information
exists for heterosexuals, but in one
study, about three-quarters were having fellatio without condoms. More
evidence comes from anecdote, which overwhelmingly indicates that people
are going down on each other without protection. (There are a handful of
documented cases of lesbians and men getting infected through cunnilingus;
while it is conceivable, there is no recorded case of a woman catching HIV
by having her vagina licked.)

Condoms prevent the sharing of semen, an
act many find extraordinarily intimate and meaningful. They also
desensitize the penis, sometimes so much that it goes limp. But for the
receptive partner in anal or vaginal intercourse, a condom doesn't make
much difference: Whether the penis is sheathed or not, the friction
remains. In fellatio, however, friction isn't usually the turn-on. Smell
and taste are what matters, and latex masks the musk. ''You might as well
not be doing it if you're not tasting skin,'' says author Erica Jong, who
swears she would ''never'' use a rubber for fellatio.

For people who won't use con
doms, there are ways to make fellatio safer. One way is to avoid having
oral sex with strangers. This is a common strategy, according to AIDS
educator Elovich, and if one's only partner is HIV-negative, it doesn't
merely reduce the risk, it eliminates it.

Many gay men have already
adopted this arrangement for anal sex: They'll fellate tricks but save
intercourse for their lover. In part, this is because blowjobs are ideal
for quick or casual encounters. So for people who like anonymous sex-and
for those whose lovers are HIV-positive-the discussion often turns to
technique.

Many people avoid the head of the penis, licking only the
shaft and testicles. This is the safest method, but people have developed
less certain ones. In order to avoid preseminal fluid, some men suck the
penis until it becomes fully erect, or for only a short time afterward.
Others pull away as soon as they taste precum. Still others won't have oral
sex if they have burned their mouth by, say, eating hot pizza.

By lowering the risk,
these strategies can also lower one's angst. But they rarely eliminate it.
''Over and over,'' says Elovich, ''I hear people dealing with anxiety: 'I
did this on Saturday night, and I felt depressed or freaked out on Sunday.
I don't want to go through another depressed Sunday, or another three
months waiting for my HIV test.' People learn to make better decisions
through the pain of that anxiety.''

Everyone's terrified,'' says
Jong. Indeed, heterosexual transmission is the fastest growing risk
category. In 1985, straight sex accounted for just 2 per cent of all U.S.
AIDS cases; last year, that figure was 11 per cent and rising. Women get
infected through heterosexual sex much more often than men, and AIDS is now
the third leading cause of death among women between the ages of 25 and
44.

But the anxiety about oral sex is more intense among gay men. ''Gay
community forums on oral sex are jammed,'' notes AIDS prevention researcher
Ron Stall. The Great Oral Sex Debate, as more than one activist call
s it, has sparked acrimonious disputes among gay leaders, with accusations
of ''internalized homophobia'' flying every which way.

The main reason
for this intensity is obvious: AIDS has been raging among gay men for 15
years. But fellatio is also ''a more central part of sex'' for them than
for heterosexuals, says Schwartz. She found that ''gay men do it for more
time, and more often to orgasm.''

Of course, many women give blowjobs
''with gusto and joy,'' as Jong puts it. ''Fellatio is about devouring.
It's very primal.'' But a surprising number of women don't like the act.
According to Sex in America, based on the landmark survey of American
sexual practices, more than four out of 10 women found giving head ''not
appealing'' or ''not at all appealing.'' Fewer than two in 10 found it
''very appealing.''

''The politics of gender inequality play into this,''
says Schwartz. For many women, fellatio ''can be seen as subservient.'' But
when there's a mutual relationship, Jong thinks many women get a ''vicarious pleasure from being in control of a man's pleasure. It's very
ego-enhancing for a woman to feel she's pleasuring her partner.''

Several
surveys affirm that fellatio is more cherished by gay men. ''A lot of gay
men don't like anal sex,'' says Schwartz, ''so what do they have left?''
That is even more true in the age of AIDS. Because condoms can break or
leak, many gay men go without anal intercourse for long periods. For them,
fellatio isn't just the biggest risk they take, it's the only
risk.

Still, the average gay man knows that fellatio is threatened, but
by a risk that is uncertain and therefore all the more unsettling.
''Because the risk is hard to define,'' says Elovich, ''oral sex has become
the site of our enormous anxiety about having sex when we're living through
the AIDS epidemic.''

Finally, there's homophobia, which has left many gay
men deeply suspicious of any limitations imposed on their sexuality. In his
book Reviving the Tribe, Rofes writes, ''Many gay men hear a subtle but familia
r message from safe sex campaigns: The meanings gay men find in their
sexual congresses are spurious, trivial, or expendable.'' In such a
climate, says Rofes, ''I want to let people know that oral sex and all sex
can be good.''

Martin Delaney, one of the epidemic's leading activists,
worries that gay leaders such as Rofes have launched ''a political response
to a medical problem. I think they've got it backwards.'' But the fact that
many gay men believe homophobia lurks in the heart of AIDS education has
made a scientific discussion of fellatio vastly more difficult.

Koopman
remembers presenting a poster at the 1988 international AIDS conference
suggesting that oral sex might be risky. Activists zapped his presentation,
chanting ''Sucking is safe!'' That protest, says Koopman ''is one of the
reasons I haven't pursued'' the investigation. At the GMHC forum, Ostrow
lambasted journalists for publicizing scientific evidence suggesting
fellatio might pose a significant danger.
To deny that fellatio has ''a va
lue and meaning that could outweigh the risks,'' Ostrow later told the
Voice, is ''sex-negative.''

''It bothers me,'' counters activist Delaney,
''that we as gay men seem to equate our entire nature with sexual acts.'' A
fulfilling sex life is valuable, he says, ''but living a long and
productive life is pretty important. And it's a pretty powerful political
act as well.''

In the midst of this psycho-political storm,
pulled by anxiety and desire, gay organizations are redefining the risk of
fellatio.

''Oral Sex Is Safer Sex,'' proclaims a poster recently
wheat-pasted around New York by the grassroots AIDS Prevention Action
League. The poster, which lists ways to make fellatio ''even safer,''
reflects an ongoing shift in AIDS prevention policy. The dominant message
used to be, ''If there's any risk at all, don't do it,'' says Ilan Meyer, a
member of APAL and an assistant professor of public health at Columbia
Univeristy. The poster, he says, defines a ''gradation of risk.'' And, he adds,
it ''counters the sexphobic advice that says, 'Just say no,' '' by
emphasizing that ''not all homosexual sex is risky.''

But activist David
Gold is worried about applying terms such as safer and low risk to oral sex
because he believes they are dangerously vague. ''They fit with what
everyone wants to hear,'' Gold says. ''Negatives will hear that it's safe
to suck, and positives will hear that they don't need to worry about
infecting their partners, or about disclosing their status before they let
someone suck them.'' Joey agrees: ''Before I got infected, safe and safer
sounded very similar. Now, having this virus in my body, the gap between
them seems a lot wider.''

GMHC has all but erased the gap. A recently
published research summary-which Meyer coauthored-concludes: ''oral sex
offers a possible, but very low, risk of HIV infection. Unprotected oral
sex is classifiable as safer sex or as safe compared to safest. (Safest can
refer to completely non-insertive forms of sex, such as masturbation and frottage.)'' The report then adds, ''Avoiding ejaculation in the mouth . . . can
lower risk of HIV transmission-and risk for other sexually transmitted
diseases-even further.'' The clear implication is that, even with ejaculate
in the mouth, oral sex is ''very low risk'' and ''safe as opposed to
safest.''

GMHC has company. The Gay and Lesbian Medical Association
recently released a report concluding that oral sex is ''low risk.'' And at
the forum in Vancouver, representatives from Canada and Germany scolded
American AIDS organizations for having toed such a conservative line for so
long on oral sex. But, as Gold and others point out, the stakes of being
wrong are much lower in those countries. In Germany, the epidemic peaks in
Berlin, where a mere 8 per cent of gay men are estimated to be
HIV-positive. In Canada's hardest-hit city, Vancouver, roughly 25 per cent
of gay men are believed to be infected. That's far less than the 40 to 50
per cent believed to be infected in San Francisco and Manhattan.

''As a positive person,'' says Tom Coates, a leading prevention expert, who objects
to the GMHC report, ''I can't imagine doing anything to infect other
people.''

Because of its worldwide stature, GMHC's report carries extra
weight-and of course the agency provides it to men who come to its
safer-sex workshops. This worries Delaney. ''How does a 20-year-old kid
respond to 'safe as opposed to safest?' '' he asks. ''It's perfectly okay
to say the risk of oral sex is less than anal sex. But to use the word safe
associated with any of this is really misleading.''

GMHC associate
executive director Mike Isbell defends the report. ''For years we gave a
red light on oral sex, and gay men ignored it,'' he explains. Trying to
learn from that experience, GMHC is trying to treat gay men ''as adults''
by providing ''more-nuanced information.'' Delaney isn't convinced: ''If
drug companies gave us data as soft as this, we'd sure scream.''

But
other AIDS experts insist that overstating the danger of oral sex, or ''erring on th
e side of caution,'' might actually cost lives. Ostrow argues that
''glorifying'' fellatio can help men redirect their desire for
''unprotected, uninhibited, mucous-membrane contact'' away from anal sex.
AIDS has left many gay men feeling fatalistic. They wonder when, not if,
they will get infected. Asserting that oral sex is very low risk might
throw them a lifeline of hope. Ostrow acknowledges that this educational
philosophy would result in some infections, but he believes it would
prevent a greater number.

Stall bristles at the ''paternalism'' of this
approach. ''We just have to give the best answers science can yield,'' he
says, ''and let people choose for themselves.'' Delaney worries about
something more sinister: ''You wonder if future evidence showed a clearer
picture of increased risk of oral sex, would they be willing to change
their views or have they dug in? Have people made this such a political
issue that they won't change?''

AIDS activism has pushed for better research into every aspect o
f the epidemic, and ''this question should not be allowed to fester in
uncertainty for another decade,'' says Delaney. Adds Gold, ''Someone should
put together a blue-ribbon panel of scientists and community people, and
have them design a study. This is so important to so many people's lives.
They deserve answers."

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